Reviewing Maternal Deaths and Complications to Make

Pregnancy and Childbirth Safer

Matthews Mathai*
Pregnancy is a normal, healthy state that
most women aspire at some point in their
lives. Yet while pregnancy and childbirth
should be an occasion for rejoicing, lifethreatening complications may occur, which
if inappropriately managed, could lead to
maternal death or disability. Most of these
deaths (99%) occur in developing countries.
Every minute, one maternal death occurs
somewhere in the developing world. Every
year over half a million women die during
pregnancy and following childbirth
174 000 of these in the South-East Asia
(SEA) Region of WHO 1 . The maternal
mortality ratio (MMR) in the SEA Region in
2000 was estimated at 460 per 100 000
live births 1 . The lifetime risk of maternal
death is 1 in 58 in this Region1 . Maternal
mortality is the proverbial tip of the iceberg.
For every maternal death, there are 20- 30
women who suffer severe morbidity. Difficult
childbirth is also a major cause of death
among newborn children.
The MMR is an indicator of the quality
of health care available during pregnancy,
childbirth and in the postpartum period. Of
all maternal deaths, 80% can be potentially
avoided by interventions during pregnancy,
childbirth and the postpartum period, that
are feasible in most countries. The common
causes
of
maternal
death
include
haemorrhage,
hypertension,
infection,
obstructed labour and unsafe abortion.
Unfortunately, national MMRs do not tell us

the real reasons why mothers die. Also one

cannot identify which women or which
groups of women or areas within a country
have higher rates of maternal mortality.
It is therefore important to look beyond
the numbers. Any planned action to reduce
mortality needs a clear understanding of
factors leading to death and the right kind of
information on which to base remediable
action. Each maternal death has a story to
tell and can provide indications on practical
ways to address the problem.

Looking Beyond the Numbers

"Beyond the Numbers: reviewing maternal
deaths and complications to make
pregnancy safer" 2 published by WHO
provides information about methodologies
to help understand why women die. These
methods include community-based death
reviews (verbal autopsy), facility-based death
reviews, and confidential enquiries/reviews
into maternal deaths. In addition to mortality
reviews, the manual deals with "near miss"
surveys and evidence-based clinical audits.
Also included are practical tools and
questionnaires that can be modified for
local use.
While all methodologies proposed are
founded on common principles, they also
have their own specific objectives and
requirements. The purpose of these

* Making Pregnancy Safer, WHO/HQ

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approaches is to stimulate action to reduce

maternal deaths and morbidity. Actions
proposed
may
involve
community
interventions as well as clinical or health
service issues. It is therefore essential that
those persons with the ability to promote
and effect the necessary changes be
involved from the start of the review process.
These approaches follow the audit
cycle: identify and review local cases
confidentially, look for avoidable factors,
promote change in practices, and review the
outcome of these changes. As no names are
included, confidentiality is assured. There is
no attribution of blame. The information is
not used for litigation or punitive action.

Methodologies
Verbal autopsy aims to find the medical
causes of death and ascertain personal,
family or community factors that may have
contributed to the death of women who died
outside a medical facility. In settings where
most women die in the community, this
approach may be the only way to study and
help avoid maternal deaths. This approach
enables
community
awareness
and
advocacy for change. However, the precise
medical cause of death may not be
determined.
Facility-based death reviews provide an
in-depth investigation of the causes and
circumstances surrounding maternal deaths
occurring in health facilities. If possible this
should be supplemented by information
about any community factors which may
have played a part in maternal death. This
exercise can lead to improvements in
individual professional practices and
development of locally applicable guidelines
or standards. However, it does not cover
deaths in the community and is not as
rigorous as clinical audit.

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Confidential enquiries or reviews into

maternal deaths is a systematic, multidisciplinary and anonymous investigation of
all or a representative sample of maternal
deaths occurring in an area, region or a
country, which identifies the numbers,
causes and avoidable or remediable factors
associated with them. Confidential reviews
provide a more complete picture of
maternal mortality than generally available
from maternal health records. Therefore,
unlike the previous two methods, this
method allows for general recommendations and guidelines to be made which
are applicable at regional or national level.
A "near miss" refers to any pregnant or
recently-delivered woman in whom
immediate survival was threatened and who
survived by chance or because of the
hospital care that she received. Severe
maternal morbidity or "near misses" occur in
larger numbers than maternal deaths. Larger
numbers provide stronger evidence and
more robust conclusions. It is also possible
to speak to the woman to obtain her views
about what happened and the care she
received. Since this can also be regarded as
a "great save", it is less threatening to staff.
However, case definition can be difficult and
requires local agreement. Case ascertainment involves time and resources. There is
no right or wrong definition of a near
miss. What is important is that the
definitions used in any review are
appropriate to local circumstances to enable
local improvements to be made in maternal
care.
Clinical audit is a quality improvement
process that seeks to improve patient care
and outcomes by a systematic review of care
against explicit criteria, and through the
implementation of change, based on the
findings. It can be used for all maternity
care, and not only for deaths and near
misses. It informs managers about the need
for organizational changes or investments. It

Regional Health Forum Volume 9, Number 1, 2005

helps to ensure that mothers receive the best

possible care in the given circumstances.
The Integrated Management of Pregnancy
and Childbirth (IMPAC) clinical guidelines3,4
can be used during the process of enquiry.

Implementation of Beyond the Numbers

in South Asia
The formal global launch of Beyond the
Numbers was in late 2004. However, the
WHO Regional Office for South-East Asia
had been active even before the formal
launch in promoting this tool for
improvement of maternal health. A regional
meeting of Member States of the SEA
Region was held in New Delhi in February
2003. Participants from Bangladesh,
Bhutan,
India,
Indonesia,
Maldives,
Myanmar, Nepal, Sri Lanka, Thailand and
Timor-Leste were asked to develop plans for
maternal death reviews. While most
countries proposed facility-based reviews,
confidential reviews were planned for Sri
Lanka and Thailand. Confidential reviews
were also proposed for Kerala state and

Vellore district in Tamil Nadu, India. Seed

money was provided by the Regional Office.
The proposals have since been implemented
in many countries and results are awaited.

Points to Remember
Each maternal death has a story to tell and
can provide indications on practical ways of
addressing the problem. Even a simple
review of one maternal death can help save
anothers life. Every health worker can be
self-reflective about why a mother died. This
can bring about a change in attitudes and
practices.
Knowing MMR is not en ough. We need
to know the underlying causes and determinants. A commitment to act upon the
findings of these reviews is a key prerequisite
to success.
Every maternal death is a tragedy. What
is an even greater tragedy is failing to learn
from why a mother died.

References
1.

Maternal Mortality in 2000. Estimates developed

by WHO, UNICEF and UNFPA. World Health
Organization, Geneva, 2004.

2.

Beyond the Numbers: Reviewing maternal deaths

and complications to make pregnancy safer.
World Health Organization, Geneva 2004.
Integrated Management of Pregnancy and
Childbirth:
Managing
complications
in

3.

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pregnancy and childbirth: a guide for midwives

and doctors. World Health Organization,
Geneva 2003.
4.

Integrated Management of Pregnancy and

Childbirth: Pregnancy, childbirth, postpartum and
newborn care: a guide for essential practice.
World Health Organization, Geneva 2003.

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